PEDS Online® Report for Glenn T
Child's name Glenn T
Date of Birth 2013-05-21
Test Age 2 years 6 months 0 day
Test date 2015-11-16
Measures Taken
PEDS-R®
PEDS:DM®
M-CHAT-R
Results
PEDS-R®
  Results PEDS-R® - Path A: High Risk for Mental Health, Social-Emotional, Behavioral and Developmental Delays/ Disorders
  Developmental Concerns: Expressive Language,Receptive Language,Fine Motor,Gross Motor,School
  Mental health, Social-Emotional, Behavioral risk: Social/Emotional,Self help
PEDS:DM®
  Results Milestones met: No milestones were met
Milestones unmet: Self Help, Fine Motor, Receptive Language, Gross Motor, Social Emotional, Expressive Language
M-CHAT-R
  Results Fail
  Failed Answer Numbers 1, 2, 3, 4, 5, 7, 8, 12
Recommendations
Provide sensory and lead screens. Refer to Early Intervention or the public schools for speech-language and psycho-educational/developmental assessments, preferably by a specialist in autism spectrum disorders. Use professional judgment to decide if referrals are also needed for social work, occupational/physical therapy, mental health services, etc.
Billing and Coding

Procedure code: 96110 for PEDS-R®, PEDS:DM® or M-CHAT-R.
Procedure code: 96112 (wRVU 2.56) for developmental testing PEDS:DM-AL®.
Procedure code: 96113 (wRVU 1.16) represents each additional 30 minute increment required to complete the service PEDS:DM-AL®.

Possible ICD-10 Codes:
F98.9 Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F82 Specific developmental disorder of motor function
F80.89 Other developmental disorders of speech or language
F90.9 Attention Deficit Hyperactivity Disorder, unspecified type
F79 Unspecified intellectual disabilities
F81.9 Developmental disorder of scholastic skills, unspecified

Record of PEDS-R® Questions and Parent Responses

Please list any concerns about your child's learning, development, and behavior.
I'm concerned about his speech and behavior

Do you have any concerns about how your child talks and makes speech sounds?
'Yes'
He repeats questions

Do you have any concerns about how your child understands what you say?
'Yes'
Yes, he doesn't respond.

Do you have any concerns about how your child uses his or her hands and fingers to do things?
'Yes'
Yes, he has some mannerisms

Do you have any concerns about how your child uses his or her arms and legs?
'Yes'
The way he holds them

Do you have any concerns about how your child behaves?
'No'

Do you have any concerns about how your child gets along with others?
'Yes'
Parallel play

Do you have any concerns about how your child is learning to do things for himself/herself?
'Yes'
yes

Do you have any concerns about how your child is learning preschool or school skills?
'Yes'
yes

Please list any other concerns.
yes

Record of PEDS:DM® Questions and Parent Responses - TEST FORM L



Can your child scribble with a crayon or marker without going off the page much?
No
Sometimes
Yes
How many of these body parts can your child point to if you say, Where is your head?"..."Where are your legs?"..."arms?"..."fingers?"..."teeth?"..."thumbs?..."toes?""
None
1-2
3 or more
When your child talks, how many words does he or she usually use at a time?
None
1
2 or more
Can your child walk backwards two steps?
No
Yes, shuffles or stops
Yes
Can your child take off loose clothes such as pull-down pants or a coat?
No
Sometimes
Most of the time
Does your child pretend to do grown-up things like taking care of a baby, sweeping, driving, or cooking?
No
Sometimes
Yes
Record of M-CHAT-R Questions and Parent Responses


1. If you point at something across the room, does your child look at it?
(FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)		 Yes  No 
2. Have you ever wondered if your child might be deaf? Yes  No 
3. Does your child play pretend or make-believe?
(FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)		 Yes  No 
4. Does your child like climbing on things?
(FOR EXAMPLE, furniture, playground equipment, or stairs)		 Yes  No 
5. Does your child make unusual finger movements near his or her eyes?
(FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)		 Yes  No 
6. Does your child point with one finger to ask for something or to get help?
(FOR EXAMPLE, pointing to a snack or toy that is out of reach)		 Yes  No 
7. Does your child point with one finger to show you something interesting?
(FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)		 Yes  No 
8. Is your child interested in other children?
(FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)		 Yes  No 
9. Does your child show you things by bringing them to you or holding them up for you to see – not to get help, but just to share?
(FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)		 Yes  No 
10. Does your child respond when you call his or her name?
(FOR EXAMPLE, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?)		 Yes  No 
11. When you smile at your child, does he or she smile back at you? Yes  No 
12. Does your child get upset by everyday noises?
(FOR EXAMPLE, does your child scream or cry to noise such as a vacuum cleaner or loud music?)		 Yes  No 
13. Does your child walk? Yes  No 
14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her? Yes  No 
15. Does your child try to copy what you do?
(FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)		 Yes  No 
16. If you turn your head to look at something, does your child look around to see what you are looking at? Yes  No 
17. Does your child try to get you to watch him or her?
(FOR EXAMPLE, does your child look at you for praise, or say “look” or “watch me”?)		 Yes  No 
18. Does your child understand when you tell him or her to do something?
(FOR EXAMPLE, if you don’t point, can your child understand “put the book on the chair” or “bring me the blanket”?)		 Yes  No 
19. If something new happens, does your child look at your face to see how you feel about it?
(FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?)		 Yes  No 
20. Does your child like movement activities?
(FOR EXAMPLE, being swung or bounced on your knee)		 Yes  No 

M-CHAT-R is copyright © 2009 Diana Robins, Deborah Fein, & Marianne Barton